HomeMy WebLinkAboutApp-Permit-ComplianceZ
No.
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1' NPKO 071�k MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Type of Building- k
Dwelling - No. of Bedrooms
Other -Type of Building
Lot Size`Z`."Tt" �C� sq. ft.
Garbage grinder(
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ����% gpd Calculated design flowj—Nk-�- Design flow provided gpd
Plan: Date umber of sheets r Revision
1►te -
1
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
The and gned agrees to ixr:
furthe a !!!�
not to place
Signed Z.
TncnPrtitin.c / � ��
Name of Soil Evaluator j� _ Date of Evaluation
above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
;em:in operation until a Certificate of Coxnplidxx a has been issued by the Board of `Health.
(' -cam i Date \_
No. •°V'FEE ^%�1
COMMONWEALTH OF MASSACHUSETTS
.�va.:-. I
Board of Health, , MA. \jk®o
CERTIFICATE Of COMPLIANCE
� Description of Work: (kI`ndividual Component(s) ❑ Complete System 7� 7
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgrade, Abandoned
at
has been installed in accordance with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
• •- 4r
pp f dated " a j' Approved'Desi i Flow
application No. 4/ (g d)
Installer �- I.. o s� .
Designer: t`) '-V Inspector: /.. ` Date: f `
The issuance of this permit shall not be construed as a guarae that the system will function as designed.
No. ,
�`��; U�- l : '"C)�7� �-- C 1 1r . C,�iVO iS/ �T1- \V, FEE �.�+ 00
Board of Health, �% (til (�.1�} , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
) an individual, sewage disposal system
at JEZ 09 i7) v} US ;E i<D`% !1 KW,7 4L as described in. the application for
Disposal System Construction Permit No. ..� %Cam, dated - /4 — .
Provided: Construction shall be completed within ths o tFlier date of this p i All local o itions must be met.
♦Porm.1255: Rev: 5/96�..A,,/M.:Sulk[
/ co. chaaestown, Ma{/"'` Date , Board of Health
> s, C i4 /, / se s .5 i✓s:9i -`�... , A, 'd�